<form name="billing_form" id="id_billing_form" >
<div >
Billing Information</div>
<center>
<span>
All fields required unless marked optional</span>
</center>
<div >
<div >
<label for="id_billing_firstname" >
First Name:</label>
<div >
<input type="text"  id="id_billing_firstname" name="billing_firstname" maxlength="40" size="25" minlength="2" onkeypress="skApp.billingShippingKeypress(event);" onchange="skApp.hasErrorVerification(event);">
</div>
</div>
<div >
<label for="id_billing_lastname" >
Last Name:</label>
<div >
<input type="text" onkeypress="skApp.billingShippingKeypress(event);" onchange="skApp.hasErrorVerification(event);"  name="billing_lastname" id="id_billing_lastname" maxlength="40">
</div>
</div>
<div  >
<label for="id_bill_addr_lookup">
Address Lookup:(optional)</label>
<div >
<input type="text"  name="bill-addr-lookup" autocomplete="on" id="bill_addr_lookup" onkeyup="addressLookup('bill_addr_lookup','bill')">
</div>
</div>
<div>
<label for="id_billing_street" >
Address:</label>
<div >
<input type="text" onkeypress="skApp.billingShippingKeypress(event);" onchange="skApp.hasErrorVerification(event);"  name="billing_street" id="id_billing_street">
</div>
</div>
<div>
<label for="id_billing_suite" >
Address 2:(optional)</label>
<div >
<input type="text" onkeypress="skApp.billingShippingKeypress(event);" onchange="skApp.hasErrorVerification(event);"  id="id_billing_suite" name="billing_suite">
</div>
</div>
<div >
<label for="id_billing_city" >
City:</label>
<div >
<input type="text" onkeypress="skApp.billingShippingKeypress(event);" onchange="skApp.hasErrorVerification(event);"  name="billing_city" id="id_billing_city">
</div>
</div>
<div id="id_state">
<label id="id_stateString">
State:</label>
<select  name="billing_state" id="id_billing_state" data-role="none" onchange="skApp.hideBillCounty(event);">
  <option value="">
Choose a state</option>
<option value="AL">
Alabama</option>
<option value="AK">
Alaska</option>
<option value="AZ">
Arizona</option>
<option value="AR">
Arkansas</option>
<option value="CA">
California</option>
<option value="CO">
Colorado</option>
<option value="CT">
Connecticut</option>
<option value="DE">
Delaware</option>
<option value="DC">
District of Columbia</option>
<option value="FL">
Florida</option>
<option value="GA">
Georgia</option>
<option value="HI">
Hawaii</option>
<option value="ID">
Idaho</option>
<option value="IL">
Illinois</option>
<option value="IN">
Indiana</option>
<option value="IA">
Iowa</option>
<option value="KS">
Kansas</option>
<option value="KY">
Kentucky</option>
<option value="LA">
Louisiana</option>
<option value="ME">
Maine</option>
<option value="MD">
Maryland</option>
<option value="MA">
Massachusetts</option>
<option value="MI">
Michigan</option>
<option value="MN">
Minnesota</option>
<option value="MS">
Mississippi</option>
<option value="MO">
Missouri</option>
<option value="MT">
Montana</option>
<option value="NE">
Nebraska</option>
<option value="NV">
Nevada</option>
<option value="NH">
New Hampshire</option>
<option value="NJ">
New Jersey</option>
<option value="NM">
New Mexico</option>
<option value="NY">
New York</option>
<option value="NC">
North Carolina</option>
<option value="ND">
North Dakota</option>
<option value="OH">
Ohio</option>
<option value="OK">
Oklahoma</option>
<option value="OR">
Oregon</option>
<option value="PA">
Pennsylvania</option>
<option value="RI">
Rhode Island</option>
<option value="SC">
South Carolina</option>
<option value="SD">
South Dakota</option>
<option value="TN">
Tennessee</option>
<option value="TX">
Texas</option>
<option value="UT">
Utah</option>
<option value="VT">
Vermont</option>
<option value="VA">
Virginia</option>
<option value="WA">
Washington</option>
<option value="WV">
West Virginia</option>
<option value="WI">
Wisconsin</option>
<option value="WY">
Wyoming</option>
<option value="AA">
Armed Forces-America</option>
<option value="AE">
Armed Forces-Europe</option>
<option value="AP">
Armed Forces-Pacific</option>
  </select>
</div>
<div >
<div >
<label for="id_billing_zipcode" >
ZIP Code:</label>
<div >
<input type="tel" onkeypress="skApp.billingShippingKeypress(event);" onchange="skApp.hideBillCounty(event)"  name="billing_zipcode" id="billing_zipcode">
</div>
</div>
<div id="billcounty-container">
</div>
</div>
<div>
<label for="billing_phonenum" >
Contact Phone:</label>
<div >
<input type="tel" onkeypress="skApp.billingShippingKeypress(event);" onchange="skApp.hasErrorVerification(event);" id="billing_phonenum"  name="billing_phonenum">
</div>
</div>
</div>
<div id="email-container">
<div id="email_id_kcmMailContent">
<div data-role="controlgroup"  aria-disabled="false" data-disabled="false" data-shadow="false" data-corners="true" data-exclude-invisible="true" data-type="vertical" data-mini="false" data-init-selector=":jqmData(role='controlgroup')">
<div >
<div id="email_id_kcmEmailAddr">
<label  for="email_id_kcmEmail_Txt">
Email</label>
<div >
<div >
<input type="email" onkeypress="skApp.billingShippingKeypress(event);" onchange="skApp.hasErrorVerification(event);" id="email_id_kcmEmail_Txt" name="email_Txt" maxlength="70" placeholder="sample@example.com" >
</div>
</div>
</div>
<div id="email_id_kcmReEmailAddr">
<label  for="email_id_kcmRe_Email_Txt">
Confirm Email Address</label>
<div >
<div >
<input type="email" onkeypress="skApp.billingShippingKeypress(event);" onchange="skApp.hasErrorVerification(event);" id="email_id_kcmRe_Email_Txt" name="re_Email_Txt" maxlength="70" placeholder="sample@example.com" >
</div>
</div>
</div>
<div >
<div >
(E-mail address is required to place an order)</div>
<div >
<div  data-role="fieldcontain">
<div >
<div >
<label for="email_kcmWS"  value="true" data-theme="c"  data-corners="true" data-shadow="false" data-iconshadow="true" data-wrapperels="span" data-icon="checkbox-on" data-mini="false">
<span >
<span >
Yes, sign me up for Sale Alerts. (optional) </span>
<span >
&nbsp;</span>
</span>
</label>
<input type="checkbox" onkeypress="skApp.billingShippingKeypress(event);" id="email_kcmWS" name="emailOutPutStatus" checked="checked" value="true">
</div>
</div>
<label >
Yes, sign me up for Sale Alerts. (optional)</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</form>


<form >
<label >
Credit Card Information</label>
<fieldset>
<legend>
</legend>
<label >
Card Type</label>
<div id="payment_id_nonEditCrdTyp">
</div>
<div id="id_cardType" >
<select id="payment_id_kcmselectPMtype"  data-role="none" name="paymentType" onchange="skApp.changePaymentDisplay(event);">
  <option value="">
Choose a card</option>
<option value="KOHLS">
Kohl's Charge</option>
<option value="AMEX">
American Express</option>
<option value="DISC">
Discover Network</option>
<option value="MC">
Mastercard</option>
<option value="VISA">
Visa</option>
  </select>
</div>
<div >
<div>
<label >
Name on Card:</label>
<div id="payment_id_kcmcard_name_div">
<label  for="payment_id_kcmcrdName_Txt">
Name on Card</label>
<div >
<div >
<input type="text" id="payment_id_kcmcrdName_Txt" onkeypress="skApp.onEnterPaymentKeypress(event);"  name="nameOnCard" value="" autocorrect="off">
</div>
</div>
</div>
<label >
Card Number:</label>
<div id="payment_id_kcmcard_number_div">
<label for="payment_id_kcmcrdNumber_Txt" >
Card Number</label>
<div >
<div >
<input type="tel" id="payment_id_kcmcrdNumber_Txt"  name="cardNumber" maxlength="16" value="">
</div>
</div>
<div id="payment_id_nonEditCrdNum" idx="">
</div>
</div>
</div>
</div>
<div >
<div>
<div id="payment_id_kcmgrid1_div">
<label >
Expiration Month:</label>
<select id="payment_id_kcmselct_expMonth" name="expMonth" data-role="none">
  <option value="">
Month</option>
<option value="01">
January</option>
<option value="02">
February</option>
<option value="03">
March</option>
<option value="04">
April</option>
<option value="05">
May</option>
<option value="06">
June</option>
<option value="07">
July</option>
<option value="08">
August</option>
<option value="09">
September</option>
<option value="10">
October</option>
<option value="11">
November</option>
<option value="12">
December</option>
  </select>
</div>
<div id="payment_id_kcmgrid2_div">
<label >
Expiration Year:</label>
<select id="payment_id_kcmselct_expYear" data-role="none" name="expYear">
  <option value="">
Year</option>
<option value="2013">
2013</option>
<option value="2014">
2014</option>
<option value="2015">
2015</option>
<option value="2016">
2016</option>
<option value="2017">
2017</option>
<option value="2018">
2018</option>
<option value="2019">
2019</option>
<option value="2020">
2020</option>
<option value="2021">
2021</option>
<option value="2022">
2022</option>
<option value="2023">
2023</option>
<option value="2024">
2024</option>
<option value="2025">
2025</option>
<option value="2026">
2026</option>
<option value="2027">
2027</option>
<option value="2028">
2028</option>
<option value="2029">
2029</option>
<option value="2030">
2030</option>
<option value="2031">
2031</option>
<option value="2032">
2032</option>
<option value="2033">
2033</option>
<option value="2034">
2034</option>
<option value="2035">
2035</option>
<option value="2036">
2036</option>
<option value="2037">
2037</option>
<option value="2038">
2038</option>
<option value="2039">
2039</option>
<option value="2040">
2040</option>
<option value="2041">
2041</option>
<option value="2042">
2042</option>
<option value="2043">
2043</option>
<option value="2044">
2044</option>
<option value="2045">
2045</option>
<option value="2046">
2046</option>
<option value="2047">
2047</option>
<option value="2048">
2048</option>
<option value="2049">
2049</option>
<option value="2050">
2050</option>
<option value="2051">
2051</option>
<option value="2052">
2052</option>
<option value="2053">
2053</option>
<option value="2054">
2054</option>
<option value="2055">
2055</option>
<option value="2056">
2056</option>
<option value="2057">
2057</option>
<option value="2058">
2058</option>
<option value="2059">
2059</option>
<option value="2060">
2060</option>
<option value="2061">
2061</option>
<option value="2062">
2062</option>
  </select>
</div>
</div>
</div>
<div id="savedPayMethList">
</div>
<div id="payment_id_kcmcard_id_div">
<label  for="payment_id_kcmNPcrdId_Txt">
Credit Card ID</label>
<div >
<div >
<input type="tel" id="payment_id_kcmNPcrdId_Txt"  name="creditCardID" maxlength="4" value="">
</div>
</div>
<div  onclick="skApp.loadWhatsMyCreditCard();">
What's my Credit Card ID?</div>
</div>
</fieldset>
</form>


